Sunday, April 2, 2017

Astute or Risky?

Half glass full? Or half glass empty? It's sort of like a perennial question to anything that sits in front of us? Born optimist? Cynic? Or a pragmatist? I suspect a lot of this runs through our lives- with the pessimists viewing the optimists as skippy,happy people without any sense of realism while the optimists see the pessimists as harbingers of doom, mood-hoovers who simply obstruct progress. A pragmatist is rare to find...and certainly difficult in the white hot emotionally driven atmosphere when it comes to that ethereal religion, the NHS.

Which brings us to the latest report from Le Beard, Simon Stevens. Now you may or may not like Roy Lilley for his views but in one of his blogs, he absolutely nails it when he says that you need to make your own mind up about the report and not be guided by others prisms- whether it be of politics, deep seated dislike of anything from private sector or indeed the basic need to suck up to the head honcho of the NHS- due to a desire to get in his "good books".
So here's my personal take- and let me remind you once again of the word "personal". It's not policy, it's not a "you have to follow my view"...it's simply a personal view after reading the document.

It's probably one of the most astute document politically I have seen for a long time (and no, I don't need to get in his good books, I am ok on that front-thanks) In short, the NHS boss has said, with the money we have, we can't deliver everything. Something's got to give- and he has started a debate. Now you could turn around and say that's outrageous but it's probably an astute way to make a politician sit up. For long, I have wondered whether politics and NHS could be separated- the bottom line is in a tax funded system, that is simply not possible. We have to work with the politicians, we have to try and convince them of the need to invest public money- and in case you haven't noticed? Megaphone diplomacy doesn't work much. Let's be brutally honest- we don't have an opposition worth its salt - so I am glad someone - apart from the colleges etc are at least trying something different. If waiting times go up, if public satisfaction starts to waver, the politicians will think again-maybe...or so goes the theory.

You could turn around and say how could one use patients as pawns- there is that- but how many times have we said either we increase funding or we start having a debate as to what needs to be prioritised? We, as a clinical community, have baulked away from the prioritisation, so I for one, am glad that at least the debate will hopefully start in earnest.

Let's look at the other side- we have a clear prioritisation of emergency care, mental health, cancer- and I don't think there can be any arguments about that. Mental health has been ignored long enough for Cinderella herself to get a complex and it's about time, it was given the front loaded approach and priority it deserves. The message is clear- NHS England has a set sum of money and with that, there are some priority areas.
There is a clear message to continue support for Vanguards aka new models of care as is the desire to get systems working together whether it be in shape of an STP or Accountable Care system. For starters, that's good, as I am tired of folks demanding return on care models within 12 months. Let me be crystal clear- folks tout our local diabetes model as an example of "working together"- it took us 5 years to show benefit. 5 years, ladies and gentlemen...new systems take time especially when dealing with population based health...we need to get out of the premiership football club mentality of sacking the Chiefs if nothing is delivered in 12-18 months.

Finally? The 18 week target. Yes, it could potentially make folks wait longer. Yes, it could make private work go up- (just a pause too to reflect that in lots of cases, it will be NHS Consultants doing that private work, not someone from outer space) but could it also be the opportunity for specialist societies to step up to the mark? Will they be brave enough to prioritise procedures based on evidence base rather than some national whim or a charity backed public push? Do all procedures need to be done...many questions...but at least they are now open. Ask acute medicine colleagues around the country how many times they have heard that an "ology" colleague couldn't possibly help out -in spite of their general medicine accreditation- as they had an 18 week target to hit. Well, maybe time to assess which of those procedures are now a priority when your hospitals front door is creaking and some, nay, any help would go down a storm.

So, yes, risks indeed- and Stevens is putting himself central at it- while making it clear to the politicians that this will have quite possibly a public bearing too. With the money there is, we either provide an average service on everything or we prioritise and provide a brilliant service on some- while putting pressure on the purse bearers to fund the bits which are slipping. To me? It's a brave call with lots at stake- and for that, credit where deserved. It could be a defining moment for the NHS depending on the response it brings from politicians in next few funding cycles. In the end, the ones who cry foul maybe right- it may also open the door for co-payments- it indeed is a high stake call- but something has to give. It is not in the NHS executive teams gift to increase taxes- that sits with the government


And to be honest? If you don't like the path taken, try and see whether you can try and galvanise a political opposition to challenge. Because that's supposed to be their job, not the role of the Chief Executive of the NHS.

As the saying goes…"We live in interesting times".

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